South Canterbury District Health Board

Size: px
Start display at page:

Download "South Canterbury District Health Board"

Transcription

1 South Canterbury District Health Board - Timaru Hospital Introduction This report records the results of a Surveillance Audit of a provider of hospital services against the Health and Disability Services Standards (NZS8134.1:2008; NZS8134.2:2008 and NZS8134.3:2008). The audit has been conducted by The DAA Group Limited, an auditing agency designated under section 32 of the Health and Disability Services (Safety) Act 2001, for submission to the Ministry of Health. The abbreviations used in this report are the same as those specified in section 10 of the Health and Disability Services (General) Standards (NZS8134.0:2008). You can view a full copy of the standards on the Ministry of Health s website by clicking here. The specifics of this audit included: Legal entity: Premises audited: South Canterbury District Health Board Timaru Hospital Services audited: Hospital services - Medical services; Hospital services - Mental health services; Hospital services - Children's health services; Hospital services - Surgical services; Hospital services - Maternity services Dates of audit: Start date: 27 October 2015 End date: 29 October 2015 Proposed changes to current services (if any): None Total beds occupied across all premises included in the audit on the first day of the audit: 69 South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 1 of 8

2 Executive summary of the audit Introduction This section contains a summary of the auditors findings for this audit. The information is grouped into the six outcome areas contained within the Health and Disability Services Standards: consumer rights organisational management continuum of service delivery (the provision of services) safe and appropriate environment restraint minimisation and safe practice infection prevention and control. General overview of the audit South Canterbury District Health Board (SCDHB) funds and provides public health services for the 55, 600 people resident in the South Canterbury District. Timaru Hospital, with 132 beds, provides medical and surgical, maternity, neo-natal and paediatric, mental health and assessment treatment and rehabilitation (ATR) services. It also provides a range of tertiary services through visiting clinicians and outreach services. This three day surveillance audit, against a subset of the Health and Disability Services Standards, included an in depth review of five patients care and four clinical systems (medication management, infection control, management of the deteriorating patient and systems to reduce patient falls). During this process auditors reviewed clinical records and other documentation, interviewed patients and their families, interviewed management and staff across a range of roles and departments, and made observations. South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 2 of 8

3 At the previous certification audit there were 30 areas identified as requiring improvement; 13 of these have been addressed and are now closed. This audit identified 19 areas that either require ongoing improvements (16) or are identified as new issues to be addressed (3). Consumer rights Areas that were identified for improvement at the last audit were followed up. Information about the Code of Rights is available, however consumers interviewed in paediatric and maternity services were unaware of the information and were not offered opportunity for explanation, discussion and clarification of their rights. Family violence screening remains an area for improvement in maternity, paediatrics, emergency department (ED) and mental health services. The privacy of mental health consumers in seclusion has been addressed satisfactorily. Work has been conducted in consultation with the Ministry of Health to address the maternity environment with the aim of encouraging good practice. Draft documents are under consideration to guide staff and access holders in regard to ensuring requirements under Section 88 Maternity Notice are met. Initiatives to improve communication with maternity consumers and between health professionals are in place or under development and work is ongoing to ensure midwives are supported to remain within their scope of practice. This area for improvement remains open. Documentation of written consent has improved, however, documentation of the risks and benefits of procedures is not consistently recorded. Advance directives for not for resuscitation orders are not consistently signed by two medical officers, when this is required. Complaints management processes are operating efficiently and are monitored. Investigations and responses to patients and staff are timely. The form now includes compliments as well as complaints and is freely available. South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 3 of 8

4 Organisational management The management of quality and risk across the SCDHB is well established with a planned quality improvement programme and quality facilitator roles that support national priorities, South Island Alliance projects and local projects. A strength of the organisation is their integrated approach across the continuum of care (the primary and secondary services). Key components of quality and risk management are linked through several forums, including the Clinical Board, Senior Leadership Team and the Patient Safety and System Improvement Committee (PSSI). Information is made available to staff and the public through ward based story boards, other well displayed project work, and an accessible Quality Account. The previous required improvement around dissemination of information has been addressed. Corrective action planning has improved with a robust system to track completion of the more significant events and complaints; however, not all quality activity recommendations are being monitored and some corrective actions have not been addressed in a timely manner, requiring further attention. Risk management meets requirements with the addition of new risks following analysis, discussion and agreement as to significance and controls. Relevant risks are reported to the Board Audit and Assurance Committee. The previous required improvement related to policies and procedures has been partially addressed but improvements are still required to ensure currency of all documents (eg, forms), that policies are based on best practice and provide sufficient guidance, that staff are aware of new policies, and that only one set of procedures is available at any one time. Monitoring and reporting on the currency of policies and procedures is ongoing and shows good progress. Adverse events are well managed, reviewed and reported and learning from investigations of significant events is evident. Improvements to departmental orientation have occurred, addressing a previous shortfall. Ongoing issues around performance appraisals for some professional groups and completion of mandatory training requirements continue. Good progress has been made in relation to medical credentialling requirements with plans in place to address those areas outstanding. Staffing requirements generally meet patient demand with examples of good team work and a flexible and responsive approach. The electronic patient acuity system and care capacity demand management project is supporting work to ensure both short and long term solutions across the services, including the medical ward where staffing levels are at a minimum. SCDHB has a stable South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 4 of 8

5 workforce, and where there are staffing vacancies identified (eg, two senior consultant roles and one pharmacy position), recruitment strategies are constantly being reviewed. The previous issue related to identifiers on the clinical records of babies has been addressed; however, there are a number of areas related to documentation that still require attention. These include ensuring records are legible and the name and designation of the person making the entry is included, and that all records are fully integrated. Continuum of service delivery Five patient journeys and four systems tracers were undertaken to review the assessment, planning, delivery and evaluation of clinical care provided to patients. The evidence affirmed the provision of care by trained professionals, using evidence based guidelines for practice. A number of service based projects since the last audit have resulted in practice improvements, for example, multidisciplinary involvement in care planning, clinical guidelines available in patients files, the e-prescribing format for medicines management and the falls prevention project. Patients and families interviewed confirmed they are satisfied with the communication, quality and timeliness of care. There is evidence of good multidisciplinary collaboration to develop patient care plans and discharge plans for patients. In the mental health area there is evidence of integration with community services and practitioners to plan inpatient care. Improvements made have resulted in the closure of a number of corrective actions. Further work is required in the areas of risk assessments, collated care plans, documentation of clinical decision making (including the early warning score), discharge planning, and verification of a registered nurse s oversight of work undertaken by student nurses and enrolled nurses. Medication management is generally well managed, however there are aspects that require further improvement, including prescribing, clinical pharmacist involvement, medicines reconciliation and vaccine storage. Opioid management was reviewed in detail identifying two areas for improvement: documentation of controlled drug security processes; and holistic pain evaluation as part of opioid management. Secure storage of medication in trolleys, ambient temperatures of stored medication areas and charting of intravenous fluid/medication volumes have been improved since the last audit addressing the required improvements. South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 5 of 8

6 Improvements have been made to a number of aspects of the food service, with improved patient satisfaction noted. In the paediatric ward the monitoring of fridge temperatures where food and breast milk is stored continues to be inconsistent. Safe and appropriate environment There are current building warrants of fitness for all buildings. There have been no required changes to the fire evacuation plans that have been approved by the New Zealand Fire Service. Trial fire evacuations are conducted, most recently in May Earthquake strengthening work is nearing completion for the Gardens Block. Improvements required at the last audit in relation to the environment have been partially addressed. Environmental cleaning in the inpatient service now meets required standards. High dusting is scheduled to re-occur in the laundry, however, it is unclear who is responsible for cleaning above and behind the machinery in the laundry. This area is visibly dusty. Changes have been made to the environment in the day procedure unit. The remaining aspects will not be completed until the planned redevelopment project is completed. This is scheduled to commence in February 2016 and is expected to take months. Policies and processes have been implemented to minimise infection control risk when adult patients are admitted to the children s ward. The renovation/refurbishment in the mental health unit has resulted in improvements to the environment. The current stage in progress, when completed, will address the required improvements to the seclusion area. Restraint minimisation and safe practice A policy and procedure provides guidance for staff on restraint minimisation practices and the use of enablers. The definitions of restraints and enablers align with the standards. The use of restraint is minimised. Bed rails are no longer approved for use as a South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 6 of 8

7 restraint. Staff are provided with education on restraint minimisation and safe practice and the use of enablers as a component of the ongoing education programme. Stitch gowns are no longer available for use in the mental health service. The Director of Area Mental Health Service has completed the necessary documentation around seclusion rooms. All four areas requiring improvement from the last audit have been addressed. Infection prevention and control Surveillance for infections is occurring. The surveillance programme is appropriate to the service setting and includes significant organisms (including multi-drug resistant organisms), specific surgical site infections, invasive device related infections, blood stream infections and outbreaks. The results are communicated appropriately. A systems approach was used to review infection control systems in detail and practices related to the identification, communication and implementation of isolation precautions for relevant patients. Areas for improvement have been identified and raised in the core standards, where appropriate. South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 7 of 8

8 Specific results for criterion where a continuous improvement has been recorded As well as whole standards, individual criterion within a standard can also be rated as having a continuous improvement. A continuous improvement means that the provider can demonstrate achievement beyond the level required for full attainment. The following table contains the criterion where the provider has been rated as having made corrective actions have been recorded. As above, criterion can be linked to the relevant standard by looking at the code. For example, a Criterion relates to Standard 1.1.1: Consumer Rights During Service Delivery in Outcome 1.1: Consumer Rights If, instead of a table, these is a message no data to display then no continuous improvements were recorded as part of this of this audit. No data to display End of the report. South Canterbury District Health Board - Timaru Hospital Date of Audit: 27 October 2015 Page 8 of 8

Lakes District Health Board

Lakes District Health Board Lakes District Health Board Introduction This report records the results of a Surveillance Audit of a provider of hospital services against the Health and Disability Services Standards (NZS8134.1:2008;

More information

Lakes District Health Board

Lakes District Health Board Lakes District Health Board Introduction This report records the results of a Certification Audit of a provider of hospital services against the Health and Disability Services Standards (NZS8134.1:2008;

More information

Taranaki District Health Board

Taranaki District Health Board Taranaki District Health Board Current Status: 15 October 2013 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted against

More information

Manis Aged Care Limited

Manis Aged Care Limited Manis Aged Care Limited Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008;

More information

Mateus Enterprises Limited

Mateus Enterprises Limited Mateus Enterprises Limited Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008;

More information

Seniorcare Geraldine Incorporated

Seniorcare Geraldine Incorporated Seniorcare Geraldine Incorporated Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards

More information

Lansdowne Park Village

Lansdowne Park Village Lansdowne Park Village Limited Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards

More information

Kaylex Care (Fielding) Limited

Kaylex Care (Fielding) Limited Kaylex Care (Fielding) Limited Introduction This report records the results of a Partial Provisional Audit of a provider of aged residential care services against the Health and Disability Services Standards

More information

Hilary Isabel Bird - Tui Glen Resthouse

Hilary Isabel Bird - Tui Glen Resthouse Hilary Isabel Bird - Tui Glen Resthouse Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards

More information

Oceania Care Company Limited - Maureen Plowman Rest Home

Oceania Care Company Limited - Maureen Plowman Rest Home Oceania Care Company Limited - Maureen Plowman Rest Home Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability

More information

Melody Enterprises Limited

Melody Enterprises Limited Melody Enterprises Limited Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008;

More information

Inspection Report. Radius Residential Care Limited. Radius Elloughton Gardens. Date of Inspection: 30 November 2016

Inspection Report. Radius Residential Care Limited. Radius Elloughton Gardens. Date of Inspection: 30 November 2016 Inspection Report Radius Residential Care Limited Radius Elloughton Gardens Date of Inspection: 30 November 2016 HealthCERT Protection Regulation and Assurance Ministry of Health 1 Table of Contents 1.

More information

SAFE STAFFING GUIDELINE

SAFE STAFFING GUIDELINE NATIONAL INSTITUTE FOR HEALTH AND CARE EXCELLENCE Guideline title SAFE STAFFING GUIDELINE SCOPE 1. Safe staffing for nursing in accident and emergency departments Background 2. The National Institute for

More information

Hilary Isabel Bird. Introduction

Hilary Isabel Bird. Introduction Hilary Isabel Bird Introduction This report records the results of a Surveillance Audit of a provider of aged residential care services against the Health and Disability Services Standards (NZS8134.1:2008;

More information

Masonic Care Limited. Introduction

Masonic Care Limited. Introduction Masonic Care Limited - Woburn Introduction This report records the results of a Partial Provisional and Surveillance Audit of a provider of aged residential care services against the Health and Disability

More information

Note: 44 NSMHS criteria unmatched

Note: 44 NSMHS criteria unmatched Commonwealth National Standards for Mental Health Services linkage with the: National Safety and Quality Health Service Standards + EQuIP- content of the EQuIPNational* Standards 1 to 15 * Using the information

More information

Masonic Care Limited - Glenwood Masonic Hospital

Masonic Care Limited - Glenwood Masonic Hospital Masonic Care Limited - Glenwood Masonic Hospital Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability

More information

West Otago Health Limited - West Otago Health

West Otago Health Limited - West Otago Health West Otago Health Limited - West Otago Health Introduction This report records the results of a Partial Provisional Audit of a provider of aged residential care services against the Health and Disability

More information

EQuIPNational Survey Planning Tool NSQHSS and EQuIP Actions 4.

EQuIPNational Survey Planning Tool NSQHSS and EQuIP Actions 4. Standard 1: Governance for safety and Quality and Standard 2: Partnering with Consumers Section 1 Governance, Policies, Business decision making, Organisational / Strategic planning, Consumer involvement

More information

Oceania Care Company Limited - Takanini Lodge

Oceania Care Company Limited - Takanini Lodge Oceania Care Company Limited - Takanini Lodge Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability Services

More information

Ambridge Rose Villa Limited - Ambridge Rose Villa

Ambridge Rose Villa Limited - Ambridge Rose Villa Ambridge Rose Villa Limited - Ambridge Rose Villa Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability

More information

NZS8134.2:2008 & NZS8134.3:2008

NZS8134.2:2008 & NZS8134.3:2008 Beta Pacifica Corporation Limited CURRENT STATUS: 22-Jul-13 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance audit conducted against

More information

Tuapeka Community Health Company Limited

Tuapeka Community Health Company Limited Tuapeka Community Health Company Limited Current Status: 5 May 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance Audit conducted

More information

Kamo Home & Village Charitable Trust - Kamo Home and Village

Kamo Home & Village Charitable Trust - Kamo Home and Village Kamo Home & Village Charitable Trust - Kamo Home and Village Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and

More information

Radius Residential Care Limited - Radius Waipuna

Radius Residential Care Limited - Radius Waipuna Radius Residential Care Limited - Radius Waipuna Introduction This report records the results of a Partial Provisional Audit of a provider of aged residential care services against the Health and Disability

More information

PATIENT ASSESSMENT POLICY Page 1 of 7

PATIENT ASSESSMENT POLICY Page 1 of 7 Page 1 of 7 Policy applies to: All staff and allied health professionals involved in patient care delivery at Mercy Hospital including Manaaki. Related Standards: Health & Disability Services (core) Standards

More information

New Vista Rest Home Limited

New Vista Rest Home Limited New Vista Rest Home Limited Current Status: 1 May 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Certification Audit conducted against the

More information

JOB DESCRIPTION. Consultant Physician, sub-specialty in Gastroenterology REPORTING TO: HEAD OF DEPARTMENT - FOR ALL CLINICAL MATTERS

JOB DESCRIPTION. Consultant Physician, sub-specialty in Gastroenterology REPORTING TO: HEAD OF DEPARTMENT - FOR ALL CLINICAL MATTERS JOB DESCRIPTION Consultant Physician, sub-specialty in Gastroenterology SECTION ONE DESIGNATION: CONSULTANT PHYSICIAN, SUB-SPECIALTY GASTROENTEROLOGY NATURE OF APPOINTMENT: FULL OR PART TIME REPORTING

More information

Standard 1: Governance for Safety and Quality in Health Service Organisations

Standard 1: Governance for Safety and Quality in Health Service Organisations Standard 1: Governance for Safety and Quality in Health Service Organisations riterion: Governance and quality improvement system There are integrated systems of governance to actively manage patient safety

More information

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Place your message here. For maximum impact, use two or three sentences. Heading Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Follow

More information

JOB DESCRIPTION. Psychiatrist REPORTING TO: CLINICAL DIRECTOR - FOR ALL CLINICAL MATTERS SERVICE MANAGER FOR ALL ADMIN MATTERS DATE: APRIL 2017

JOB DESCRIPTION. Psychiatrist REPORTING TO: CLINICAL DIRECTOR - FOR ALL CLINICAL MATTERS SERVICE MANAGER FOR ALL ADMIN MATTERS DATE: APRIL 2017 JOB DESCRIPTION Psychiatrist SECTION ONE DESIGNATION: CONSULTANT PSYCHIATRIST MEDICAL OFFICER PSYCHIATRY NATURE OF APPOINTMENT: FULL TIME/10/10THS FTE LOCATION: WEEKLY TIMETABLE: INDICATIVE ONLY REPORTING

More information

Howick Baptist Healthcare Limited

Howick Baptist Healthcare Limited Howick Baptist Healthcare Limited Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability Services Standards

More information

Towards Quality Care for Patients. National Core Standards for Health Establishments in South Africa Abridged version

Towards Quality Care for Patients. National Core Standards for Health Establishments in South Africa Abridged version Towards Quality Care for Patients National Core Standards for Health Establishments in South Africa Abridged version National Department of Health 2011 National Core Standards for Health Establishments

More information

NON-MEDICAL PRESCRIBING POLICY

NON-MEDICAL PRESCRIBING POLICY NON-MEDICAL PRESCRIBING POLICY To be read in conjunction with the Medicines Policy, Controlled Drug Policy and the FP10 Prescribing Forms Policy Version: 5 Date of issue: August 2017 Review date: August

More information

The Ultimate Care Group Limited - Ultimate Care Aroha

The Ultimate Care Group Limited - Ultimate Care Aroha The Ultimate Care Group Limited - Ultimate Care Aroha Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability

More information

Focussed Independent Healthcare Inspection (Unannounced)

Focussed Independent Healthcare Inspection (Unannounced) Focussed Independent Healthcare Inspection (Unannounced) St Joseph's Hospital, Newport Inspection date: 21 November 2017 Publication date: 22 February 2018 This publication and other HIW information can

More information

Oceania Care Company Limited - Eldon Rest Home

Oceania Care Company Limited - Eldon Rest Home Oceania Care Company Limited - Eldon Rest Home Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability Services

More information

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Place your message here. For maximum impact, use two or three sentences. Heading Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Follow

More information

Quality Standards CLINICAL AND QUALITY GOVERNANCE. Version 1.2

Quality Standards CLINICAL AND QUALITY GOVERNANCE. Version 1.2 Quality s CLINICAL AND QUALITY GOVERNANCE Version 1.2 October 2015 8831 October 2015 West Midlands Quality Review Service These Quality s may be reproduced and used freely by NHS and social care organisations

More information

Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36

Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36 Healthcare-associated infections: prevention ention and control Public health guideline Published: 11 November 2011 nice.org.uk/guidance/ph36 NICE 2017. All rights reserved. Subject to Notice of rights

More information

Bruce McLaren Retirement Village Limited

Bruce McLaren Retirement Village Limited Bruce McLaren Retirement Village Limited Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability Services

More information

TRUST BOARD. Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director. Jo Hunter, Deputy Chief Nurse. Mary Heritage, Assistant Director of Quality

TRUST BOARD. Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director. Jo Hunter, Deputy Chief Nurse. Mary Heritage, Assistant Director of Quality TRUST BOARD Document Title: Presenter: Quality Report Jo Hunter, Deputy Chief Nurse Authors: Contact details for further information: Jo Furley, Interim Chief Nurse Dr Ben Lobo, Medical Director Jo Hunter,

More information

Oceania Care Company Limited - Lady Allum

Oceania Care Company Limited - Lady Allum Oceania Care Company Limited - Lady Allum Current Status: 13 October 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance Audit conducted

More information

Care of Critically Ill & Critically Injured Children in the West Midlands

Care of Critically Ill & Critically Injured Children in the West Midlands Care of Critically Ill & Critically Injured Children in the West Midlands Heart of England NHS Foundation Trust Visit Date: 3 rd and 4 th October 2013 Report Date: December 2013 Images courtesy of NHS

More information

Care Alliance 2016 Limited - Waimarie Private Hospital

Care Alliance 2016 Limited - Waimarie Private Hospital Care Alliance 2016 Limited - Waimarie Private Hospital Introduction This report records the results of a Provisional Audit of a provider of aged residential care services against the Health and Disability

More information

Trust Board Meeting: Wednesday 12 March 2014 TB Peer Review Programme Implementation Update

Trust Board Meeting: Wednesday 12 March 2014 TB Peer Review Programme Implementation Update Trust Board Meeting: Wednesday 12 March 2014 Title Peer Review Programme Implementation Update Status History For discussion Papers providing updates on the process and outcomes of the Peer Review Programme

More information

Doncaster and Bassetlaw Hospitals NHS Foundation Trust

Doncaster and Bassetlaw Hospitals NHS Foundation Trust Doncaster and Bassetlaw Hospitals NHS Foundation Trust Doncaster Royal Infirmary Quality Report Armthorpe Road Doncaster DN2 5LT Tel: 01302 366666 Website: www.dbh.nhs.uk Date of inspection visit: 14 17

More information

Consumers Union/Safe Patient Project Page 1 of 7

Consumers Union/Safe Patient Project Page 1 of 7 Improving Hospital and Patient Safety: An overview of recently passed legislation and requirements towards improving the safety of California s hospital patients June 2009 Background Since 2006 several

More information

Maidstone and Tunbridge Wells NHS Trust

Maidstone and Tunbridge Wells NHS Trust Maidstone and Tunbridge Wells NHS Trust Quality report Tonbridge Road Pembury Tunbridge Wells Kent TN2 4QJ Tel: 01892 823535 www.mtw.nhs.uk Date of inspection visit: 14-16 October 2014 Date of publication:

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Marie Curie Hospice Liverpool Speke Road, Woolton, Liverpool,

More information

Prevention and control of healthcare-associated infections

Prevention and control of healthcare-associated infections Prevention and control of healthcare-associated infections Quality improvement guide Issued: November 2011 NICE public health guidance 36 guidance.nice.org.uk/ph36 NHS Evidence has accredited the process

More information

Overall rating for this trust Good. Inspection report. Ratings. Are services safe? Requires improvement. Are services effective?

Overall rating for this trust Good. Inspection report. Ratings. Are services safe? Requires improvement. Are services effective? Barnsley Hospital NHS Foundation Trust Inspection report Gawber Road Barnsley South Yorkshire S75 2EP Tel: 01226 730000 www.barnsleyhospital.nhs.uk Date of inspection visit: 17 to 19 October, 15 to 17

More information

Unannounced Care Inspection Report 9 March Orchard Grove

Unannounced Care Inspection Report 9 March Orchard Grove Unannounced Care Inspection Report 9 March 2017 Orchard Grove Type of service: Residential care home Address: 7 The Square, Clough, BT30 8RB Tel no: 028 4481 1672 Inspector: Alice McTavish w w w. r q i

More information

Golden Concept Group (NZ) Limited - Eversleigh Hospital

Golden Concept Group (NZ) Limited - Eversleigh Hospital Golden Concept Group (NZ) Limited - Eversleigh Hospital Introduction This report records the results of a Provisional Audit of a provider of aged residential care services against the Health and Disability

More information

Worcestershire Acute Hospitals NHS Trust

Worcestershire Acute Hospitals NHS Trust Worcestershire Acute Hospitals NHS Trust Worcestershire Royal Hospital Quality Report Charles Hastings Way Worcester WR5 1DD Tel: 01905 763333 Website: www.worcsacute.nhs.uk Date of inspection visit: 12,

More information

Unannounced Inspection Report: Independent Healthcare

Unannounced Inspection Report: Independent Healthcare Unannounced Inspection Report: Independent Healthcare Marie Curie Hospice - Edinburgh Marie Curie Cancer Care Edinburgh 22 May 2013 Healthcare Improvement Scotland is committed to equality. We have assessed

More information

JOB DESCRIPTION. The hospital has been consistently growing over the past few years, almost doubling since 2008.

JOB DESCRIPTION. The hospital has been consistently growing over the past few years, almost doubling since 2008. JOB DESCRIPTION JOB TITLE: Senior II Paediatric Physiotherapist CLINICAL UNIT: Therapy Services BASE: The Portland Hospital for Women and Children MANAGED BY: Therapy Services Manager/ Senior staff ACCOUNTABLE

More information

The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England

The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England Report by the Comptroller and Auditor General The Management and Control of Hospital Acquired Infection in Acute NHS Trusts in England Ordered by the House of Commons to be printed 14 February 2000 LONDON:

More information

HEI self-assessment. Completing the self-assessment - Guidance to NHS boards

HEI self-assessment. Completing the self-assessment - Guidance to NHS boards HEI self-assessment Completing the self-assessment - Guidance to NHS boards INTRODUCTION This document should be read in conjunction Healthcare Improvement Scotland healthcare associated infection (HAI)

More information

Performance audit report. Effectiveness of arrangements to check the standard of rest home services: Follow-up report

Performance audit report. Effectiveness of arrangements to check the standard of rest home services: Follow-up report Performance audit report Effectiveness of arrangements to check the standard of rest home services: Follow-up report Office of the Auditor-General PO Box 3928, Wellington 6140 Telephone: (04) 917 1500

More information

Unannounced Inspection Report. Aberdeen Maternity Hospital NHS Grampian. 9 October 2013

Unannounced Inspection Report. Aberdeen Maternity Hospital NHS Grampian. 9 October 2013 Unannounced Inspection Report Aberdeen Maternity Hospital NHS Grampian 9 October 2013 The Healthcare Environment Inspectorate is a part of Healthcare Improvement Scotland Healthcare Improvement Scotland

More information

Manis Aged Care No 1 Limited

Manis Aged Care No 1 Limited Manis Aged Care No 1 Limited Current Status: 1 September 2014 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Provisional Audit conducted against

More information

Designated Auditing Agency Handbook. Ministry of Health Auditor Handbook (revised 2016)

Designated Auditing Agency Handbook. Ministry of Health Auditor Handbook (revised 2016) Designated Auditing Agency Handbook Ministry of Health Auditor Handbook (revised 2016) For Health and Disability Services Standards NZS 8134:2008 Released 2016 health.govt.nz Ministry of Health requirements

More information

Overall rating for this trust. Quality Report. Ratings

Overall rating for this trust. Quality Report. Ratings Worcestershire Acute Hospitals NHS Trust Quality Report Worcestershire Royal Hospital Charles Hastings Way Worcester WR5 1DD Tel: : 01905 763333 Website: www.worcsacute.nhs.uk Date of inspection visit:

More information

Craigweil House Care Limited - Craigwell House

Craigweil House Care Limited - Craigwell House Craigweil House Care Limited - Craigwell House Introduction This report records the results of a Certification Audit of a provider of aged residential care services against the Health and Disability Services

More information

Quality & Clinical Governance Report 2013

Quality & Clinical Governance Report 2013 Quality & Clinical Governance Report 2013 Teresa Read Quality Manager April 2013 1 Contents - to be rewritten Appendices: 1. External audit Summary 2 1 Foreword This report provides an overview of the

More information

Improve, Inspire, Innovate Quality Improvement Plan

Improve, Inspire, Innovate Quality Improvement Plan Improve, Inspire, Innovate Quality Improvement Plan 1 QIP Final version 20170706 Contents Background & Summary Page 3 Who is Responsible? Page 4 How will we communicate our progress to you? Page 4 Chair

More information

Your guide to the CQC Fundamental Standards

Your guide to the CQC Fundamental Standards Your guide to the CQC Fundamental Standards RDaSH Introduction In order to get to the heart of people s experiences of care and support, the focus of the Care Quality Commission (CQC) Regulatory Framework

More information

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards.

We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Inspection Report We are the regulator: Our job is to check whether hospitals, care homes and care services are meeting essential standards. Laureate House Laureate House, Wythenshawe Hospital, Southmoor

More information

Date of publication:june Date of inspection visit:18 March 2014

Date of publication:june Date of inspection visit:18 March 2014 Jubilee House Quality Report Medina Road, Portsmouth PO63NH Tel: 02392324034 Date of publication:june 2014 www.solent.nhs.uk Date of inspection visit:18 March 2014 This report describes our judgement of

More information

Medicines Management Strategy

Medicines Management Strategy Medicines Management Strategy 2012 2014 Directorate responsible for the strategy: Medical and Governance Directorate Staff group to whom it applies: All clinical staff and Trust managers Issue date: 30/6/12

More information

Report. Leigh House, Specialised Services Winchester

Report. Leigh House, Specialised Services Winchester Report Leigh House, Specialised Services Winchester Thursday 23 rd February 2012 Overall Impression Leigh house appeared to have a calm and relaxed atmosphere with a non-clinical feel, a nice environment

More information

CCDM Programme Standards

CCDM Programme Standards CCDM Programme Standards Standard 1.0 CCDM Governance Standard 1.0 The CCDM governance councils (organisation and ward/unit) ensure that care capacity demand management is planned, coordinated and appropriate

More information

Kiri Te Kanawa Retirement Village

Kiri Te Kanawa Retirement Village Kiri Te Kanawa Retirement Village Limited - Kiri Te Kanawa Retirement Village Introduction This report records the results of a Certification Audit of a provider of aged residential care services against

More information

Overall rating for this trust Requires improvement. Inspection report. Ratings. Are services safe? Requires improvement. Are services effective?

Overall rating for this trust Requires improvement. Inspection report. Ratings. Are services safe? Requires improvement. Are services effective? University Hospitals of Leicesterer NHS Trust Inspection report Trust HQ, Level 3 Balmoral Leicester Royal Infirmary Leicester Leicestershire LE1 5WW Tel: 0300 303 1573 www.leicestershospitals.nhs.uk Date

More information

INFECTION CONTROL SURVEILLANCE POLICY

INFECTION CONTROL SURVEILLANCE POLICY INFECTION CONTROL SURVEILLANCE POLICY Version: 3 Ratified by: Date ratified: July 2016 Title of originator/author: Title of responsible committee/group: Senior Managers Operational Group Head of Infection

More information

Anaesthesia Fellow. Position Description. Department : Department of Anaesthesia & Perioperative Medicine

Anaesthesia Fellow. Position Description. Department : Department of Anaesthesia & Perioperative Medicine Job Title : Anaesthesia Fellow Department : Department of Anaesthesia & Perioperative Medicine Location : Waitemata District Health Board Reporting To : Clinical Director Anaesthesia Direct Reports : Anaesthesia

More information

Observatory Village Charitable Trust - Observatory Village Lifecare

Observatory Village Charitable Trust - Observatory Village Lifecare Observatory Village Charitable Trust - Observatory Village Lifecare Introduction This report records the results of a Partial Provisional Audit of a provider of aged residential care services against the

More information

Associate Director of Patient Safety and Quality on behalf of the Director of Nursing and Clinical Governance

Associate Director of Patient Safety and Quality on behalf of the Director of Nursing and Clinical Governance APPENDIX 5 BOARD OF DIRECTORS 18 JUNE 2014 Report to: Report from: Subject: Board of Directors Associate Director of Patient Safety and Quality on behalf of the Director of Nursing and Clinical Governance

More information

2016/17 Estimates for Vote Health

2016/17 Estimates for Vote Health 2016/17 Estimates for Vote Health Report of the Health Committee Contents Recommendation 2 Introduction 2 Mental health services 2 Disability support services 4 National Bowel Screening Programme 4 Burwood

More information

Report of an inspection of a Designated Centre for Older People

Report of an inspection of a Designated Centre for Older People Report of an inspection of a Designated Centre for Older People Name of designated centre: Name of provider: Address of centre: Kiltipper Woods Care Centre Kiltipper Woods Care Centre Kiltipper Road, Tallaght,

More information

NHSLA Risk Management Standards

NHSLA Risk Management Standards NHSLA Risk Management Standards 2012-13 for NHS Trusts providing Acute Services Brighton and Sussex University Hospitals NHS Trust Level 1 October 2012 Contents Executive Summary... 3 Assessment Outcome...

More information

Registration and Inspection Service

Registration and Inspection Service Registration and Inspection Service Children s Residential Centre Centre ID number: 020 Year: 2017 Lead inspector: Michael McGuigan Registration and Inspection Services Tusla - Child and Family Agency

More information

Safe Care and Support

Safe Care and Support SPECIALIST PALLIATIVE CARE May 2014 Safe Care and Support Supporting services to deliver quality healthcare 1 Introduction Welcome to the Quality Assessment and Improvement Workbook. This workbook will

More information

GOVERNING BODY REPORT

GOVERNING BODY REPORT GOVERNING BODY REPORT 1. Date of Governing Body Meeting 16 th November 2017 2. Title of Report: 3. Key Messages: BUPA ceased to be the registered provider of Crawfords Walk Nursing Home in October. The

More information

Residents and family members interviewed spoke positively of the services provided at PSC Huntleigh.

Residents and family members interviewed spoke positively of the services provided at PSC Huntleigh. Presbyterian Support Central - Huntleigh CURRENT STATUS: 19-Sep-13 The following summary has been accepted by the Ministry of Health as being an accurate reflection of the Surveillance audit conducted

More information

After the self-assessment Next Steps

After the self-assessment Next Steps After the self-assessment Next Steps IFC Self-Assessment Guide for Health Care Organizations 75 After the Self-Assessment Next Steps STEP 4: Performance and Identify Gaps After completing the assessment,

More information

JOB DESCRIPTION. The hospital has been consistently growing over the past few years, almost doubling since 2008.

JOB DESCRIPTION. The hospital has been consistently growing over the past few years, almost doubling since 2008. JOB DESCRIPTION JOB TITLE: Paediatric Pre Assessment Nurse CLINICAL UNIT: Paediatric Department BASE: The Portland Hospital for Women and Children MANAGED BY: Children s Services Manager ACCOUNTABLE TO:

More information

IQ Action Plan: Supporting the Improving Quality Approach

IQ Action Plan: Supporting the Improving Quality Approach IQ Action Plan: Supporting the Improving Quality Approach i ii Citation: Minister of Health. 2003.. Wellington:. Published in September 2003 by the PO Box 5013, Wellington, New Zealand ISBN 0-478-25800-3

More information

Trust Board Meeting: Wednesday 13 May 2015 TB

Trust Board Meeting: Wednesday 13 May 2015 TB Trust Board Meeting: Wednesday 13 May 2015 Title Update on Quality Governance Framework Status History For information, discussion and decision This paper has been presented to Quality Committee in April

More information

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Place your message here. For maximum impact, use two or three sentences. F Heading Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland

More information

Handover of Care (Maternity) Guidelines Author s job title Lead Clinical Midwife Department Ladywell Unit. Comment / Changes / Approval

Handover of Care (Maternity) Guidelines Author s job title Lead Clinical Midwife Department Ladywell Unit. Comment / Changes / Approval Document Control Title Author Directorate Surgery Date Version Issued 0.1 Oct 2009 0.2 Nov 2009 1.0 Nov 2009 1.1 Feb 2010 2.0 Feb 2010 2.1 Aug 2011 2.2 Oct 2011 Handover of Care (Maternity) Guidelines

More information

Shetland NHS Board. Board Paper 2017/28

Shetland NHS Board. Board Paper 2017/28 Board Paper 2017/28 Shetland NHS Board Meeting: Paper Title: Shetland NHS Board Capacity and resilience planning - managing safe and effective care across hospital and community services Date: 11 th June

More information

Improvement and assessment framework for children and young people s health services

Improvement and assessment framework for children and young people s health services Improvement and assessment framework for children and young people s health services To support challenged children and young people s health services achieve a good or outstanding CQC rating February

More information

The Australian Council on Healthcare Standards NATIONAL REPORT ON HEALTH SERVICES ACCREDITATION PERFORMANCE

The Australian Council on Healthcare Standards NATIONAL REPORT ON HEALTH SERVICES ACCREDITATION PERFORMANCE 27 28 The Australian Council on Healthcare Standards NATIONAL REPORT ON HEALTH SERVICES ACCREDITATION PERFORMANCE The Australian Council on Healthcare Standards National Report on Health Services Accreditation

More information

No Title Project Objective Change Model

No Title Project Objective Change Model 1 Introducing a Systematic Approach to To introduce a Clozapine Monitoring structured and systematic approach to monitoring and addressing the adverse effects of clozapine. 2 Dental Care for Baby Teeth

More information

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland

Heading. Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Place your message here. For maximum impact, use two or three sentences. Heading Safeguarding of Children and Vulnerable Adults in Mental Health and Learning Disability Hospitals in Northern Ireland Follow

More information

HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals. One Year Later

HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals. One Year Later HIQA s Medication Safety Monitoring Programme in Public Acute Hospitals One Year Later Sean Egan Head of Healthcare Regulation Health Information and Quality Authority Presentation outline Recap on the

More information

NURSING SCOPE OF PRACTICE POLICY Page 1 of 10 July 2016

NURSING SCOPE OF PRACTICE POLICY Page 1 of 10 July 2016 Page 1 of 10 NB: Anaesthetic RN Policy has been incorporated into this policy Policy Applies to: All Mercy Hospital Nursing staff Related Standards: Health Practitioners Competency Assurance Act (HPCA)

More information

Promoting Effective Immunisation Practice Guide for Students, Mentors and Their Employers Updated Click Here

Promoting Effective Immunisation Practice Guide for Students, Mentors and Their Employers Updated Click Here Promoting Effective Immunisation Practice Guide for Students, Mentors and Their Employers Updated 2014 Click Here Promoting Effective Immunisation Practice Published Summer 2014 NHS Education for Scotland

More information